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Guidelines for Documentation of Occupational
Therapy
Documentation of occupational therapy services is required whenever professional services are provided
1 2
to a client. Occupational therapy practitioners identify the types of documentation required and record
all necessary components of services provided within their scope of practice. This document, based on
the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; American Occupational Therapy
Association [AOTA], 2014b), describes the purpose, types, and content of professional documentation used
in occupational therapy.
AOTA’s (2015c) Standards of Practice for Occupational Therapy states that an occupational therapy practitioner
documents the occupational therapy services and “abides by the time frames, formats, and standards es-
tablished by practice settings, federal and state laws, other regulatory and payer requirements, external
accreditation programs, and AOTA documents” (p. 4). These requirements apply to both electronic and
written forms of documentation though may vary considerably by practice setting and facility. AOTA’s
(2015a) Occupational Therapy Code of Ethics states that occupational therapy practitioners “shall promote
fairness and objectivity in the provision of occupational therapy services” (p. 5) and “shall provide com-
prehensive, accurate, and objective information when representing the profession” (p. 6).
Occupational therapy documentation reflects the nature of services provided, shows the clinical reason-
ing of the occupational therapy practitioner, and provides enough information to ensure that services are
delivered in a safe and effective manner. Documentation describes the depth and breadth of services pro-
vided to meet the complexity of client needs and responses to occupational therapy services at the individ-
ual, group (community), or population levels.
The purpose of documentation is to
• Communicate information about the client’s occupational history and experiences, interests, values, and
needs;
• Articulate the rationale for provision of occupational therapy services and the relationship of those ser-
vices to client outcomes;
• Provide a clear chronological record of client status, the nature of occupational therapy services provided,
client response to occupational therapy intervention, and client outcomes; and
• Provide an accurate justification for skilled occupational therapy service necessity and
reimbursement.
1
In this document, client may refer to persons, groups, and populations (AOTA, 2014b).
2When the term occupational therapy practitioner is used in this document, it refers to both occupational therapists and occupational
therapy assistants (AOTA, 2015b). Occupational therapists are responsible for all aspects of occupational therapy service delivery and
are accountable for the safety and effectiveness of the occupational therapy service delivery process. Occupational therapy assistants
deliver occupational therapy services under the supervision of and in partnership with an occupational therapist (AOTA, 2014a).
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The RefeRence Manual of The official DocuMenTs of The aMeRican occupaTional TheRapy as so ci a Tion, inc.
Types of Documentation
Documentation of occupational therapy service is maintained in a professional and legal fashion (i.e., com-
plete, concise, accurate, timely, legible, clear, grammatically correct, objective) for each client served. Table 1
outlines common types of documentation used by occupational therapy practitioners.
Documentation types may be identified differently or combined and reorganized to meet the specific needs
of the client and setting. Occupational therapy documentation provides a record of the practitioner’s ac-
tivity in the areas of screening, evaluation and reevaluation, intervention, and outcomes (AOTA, 2014b) in
accordance with practice guidelines and payer, facility, and state and federal guidelines and requirements.
In addition, Box 1 lists the fundamental elements of documentation.
Content of Documentation
I. Screening Report—Documents the referral source and the reason for occupational therapy screening.
A. Referral information—Date and source of referral, services requested, and reason for referral.
B. Client information—Description of client’s occupational history, experiences, and performance;
health status; and applicable medical, educational, and developmental diagnoses, precautions,
and contraindications.
C. Brief occupational profile—Client’s reason for seeking occupational therapy services; areas of occu-
pation in which the client is successful and challenged; contexts and environments that support
and hinder occupational performance (e.g., patterns of living, interest, values); medical, educa-
tional, and work history; client’s priorities; and targeted goals (AOTA, 2017).
Table 1. Common Types of Occupational Therapy Documentation
Process Area Type
I. Screening A. Screening Report
II. Evaluation/Reevaluation A. Evaluation Report
B. Reevaluation Report
III. Intervention A. Intervention Plan
B. Contact Report
C. Progress Report
D. Transition Plan
IV. Outcomes A. Discharge/Discontinuation Report
Box 1. Fundamentals of Documentation
• Documentation practices and storage and disposal of documentation must meet all state and federal regulations and guidelines, payer and
facility requirements, practice guidelines, and confidentiality requirements.
Client’s full name, date of birth, gender, and case number, if applicable, are included on each page of the documentation.
•
Identification of type of documentation and the date service is provided and documentation is completed are included in the
•
documentation.
Acceptable terminology, acronyms, and abbreviations are defined and used within the boundaries of the setting.
•
Clear rationale for the purpose, value, and necessity of skilled occupational therapy services is provided. The client’s diagnosis or prognosis
•
is not the sole rationale for occupational therapy services.
Professional signature (first name or initial, last name) and credential; cosignature and credential when required for documentation of
•
supervision; and, when necessary, signature of the recorder are included with each documentation entry.
All errors are noted and initialed or signed.
•
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I.E. Guidelines
D. Assessments used (if any) and results—Types of assessments used and results (e.g., interviews,
record reviews, observations).
E. Recommendation—Professional judgments regarding need for complete occupational therapy
evaluation, based on results of the assessments.
II. Evaluation Report—Documents the referral source and data gathered through the occupational
therapy evaluation process.
A. Referral information—Date and source of referral, services requested, and reason for referral.
B. Client information—Description of client’s occupational history, experiences, and performance;
health status and previous services required and accessed; and applicable medical, educational,
and developmental diagnoses, precautions, and contraindications.
C. Occupational profile—Client’s reason for seeking occupational therapy services; areas of occupa-
tion in which the client is successful and challenged; contexts and environments that support and
hinder occupational performance; medical, educational, and work history; occupational and psy-
chosocial history (e.g., patterns of living, interest, values); client’s priorities; and targeted goals
(AOTA, 2017).
D. Assessments used and results—Types of assessments used (e.g., interviews, record reviews, obser-
3
vations, standardized or nonstandardized assessments) and description of results.
E. Analysis of occupational performance—Analysis of occupational performance and identification
of factors that support and hinder performance and participation (objective and measurable
identification of performance skills, performance patterns, contexts and environments, activity
demands, outcomes from standardized or nonstandardized assessments, and client factors).
F. Summary and analysis—Interpretation and summary of the occupational profile and occupational
performance issues, identification of targeted areas of occupation and occupational performance
to be addressed, and expected outcomes. The American Medical Association’s (2018) Current
Procedural Terminology (CPT) requires that procedural codes based on levels of complexity (low,
moderate, high) be identified for the three main components of the occupational therapy evalu-
ation: (1) occupational profile and medical and therapy history, (2) assessments of occupational
performance (including identification of performance deficits to be addressed in the plan of care),
and (3) clinical decision making. Medicare, Medicaid, and other insurance providers and payers
use these codes to identify service reimbursement (Centers for Medicare and Medicaid Services
[CMS], 2017a).
When required for clients covered by Medicare or Medicaid, data on the client’s primary func-
tional limitation is reported in the form of quality data codes (G-codes) with their corresponding
severity and therapy modifiers (CMS, 2017b). Functional limitation reporting (FLR) provides
G-codes in the areas of mobility and self-care. When addressing population health needs, an
environmental scan or SWOT (strengths, weaknesses, opportunities, threats) is often used to
document the summary and analysis (Jacobs, Van Witteloostuijn, & Christe-Zeyse, 2013).
G. Recommendation—Judgment regarding necessity for skilled occupational therapy services or oth-
er services.
III. Reevaluation Report—Documents the occupational therapy reevaluation process. Continual
assessment is a component of ongoing therapy services. Formal reevaluation is conducted when,
3Nonstandardized assessment tools are considered a valid form of information gathering that allows for flexibility and individual-
ization when measuring outcomes related to the status of an individual or group through an intrapersonal comparison. Although
not uniform in administration or scoring or possessing full and complete psychometric data, nonstandardized assessment tools have
strong internal validity and represent an evidence-based approach to occupational therapy practice (Hinojosa, Kramer, & Christ,
2010). Nonstandardized tools should be selected on the basis of the best available evidence and the clinical reasoning of the occupa-
tional therapist.
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The RefeRence Manual of The official DocuMenTs of The aMeRican occupaTional TheRapy as so ci a Tion, inc.
in the professional judgment of the occupational therapist, new clinical findings emerge, a signif-
icant change in the patient’s condition requiring further tests and measures is observed, the client
demonstrates a lack of response as expected in the plan of care, or additional information is required
for discharge (CMS, 2017b) or when required by practice guidelines and payer, facility, and state and
federal guidelines and requirements.
A. Client information—Description of client’s occupational history, experiences, and performance;
health status; and applicable medical, educational, and developmental diagnoses, precautions,
and contraindications.
B. Occupational profile—Updates on current areas of occupation that are successful and problematic;
contexts and environments that support or hinder occupations; summary of any new medical,
educational, and work information; and updates or changes to client’s priorities and targeted
outcomes (AOTA, 2017).
C. Reevaluation results—Focus of reevaluation, specific types of outcome measures from standard-
ized or nonstandardized assessments used, and results.
D. Analysis of occupational performance—Analysis of occupational performance and identification
of factors that support and hinder performance and participation (objective and measurable
identification of performance skills, performance patterns, contexts and environments, activity
demands, outcomes from standardized and nonstandardized assessments, and client factors).
E. Summary and analysis—Interpretation and summary of occupational profile and performance
issues, identification of targeted areas of occupation and occupational performance to be
addressed, and expected outcomes. There is one CPT code available for the identification of the
service of reevaluation (CMS, 2017a). In the case of clients covered by Medicaid and Medicare,
FLR G-codes with their corresponding severity and therapy modifiers may be required (CMS, 2017b).
F. Recommendations—Changes to occupational therapy services; revision or continuation of inter-
ventions; goals and objectives; frequency of occupational therapy services; and recommendation
for referral to other professionals or agencies, as applicable.
IV. Intervention Plan (Plan of Care)—Documents the goals and the intervention types and approaches
to be used in the occupational therapy process on the basis of the results of evaluation or reevalua-
tion processes. Physician certification of Intervention Plans (Plans of Care) may be required by state
practice acts and third-party payers, including Medicare and Medicaid.
A. Client information—Precautions and contraindications.
B. Intervention goals—Measurable and meaningful occupation-based long-term and short-term
goals directly related to the client’s ability and need to engage in desired occupations and to the
justification of the need for skilled occupational therapy intervention to meet the goals. Goals are
based on the evaluation or reevaluation in adherence with each payer source’s documentation
requirements (e.g., pain levels, time spent on each intervention).
C. Intervention approaches and types of interventions to be used—Intervention approaches that include
create/promote, establish/restore, maintain, modify, and prevent; types of interventions that
include consultation, education process, advocacy, and the therapeutic use of occupations or
activities used within individual or group sessions.
D. Service delivery mechanisms—Service provider, service location, and frequency, intensity, and du-
ration of services for the individual needs of the client.
E. Plan for discharge—Discontinuation criteria, discharge setting (e.g., skilled nursing facility, home,
community, classroom), and anticipated follow-up care.
F. Outcome measures—Tools that assess occupational performance, adaptation, role competence,
improved health and wellness, improved quality of life, self-advocacy, and occupational
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